Allan House

Depression after stroke and lesion location: a systematic review

BACKGROUND There is conflicting evidence on the hypothesis that the risk of depression after stroke is influenced by the location of the brain lesion. We undertook a systematic review to examine the hypotheses that depression is more commonly associated with left-hemisphere strokes than with right-hemisphere strokes and with lesions of the left anterior brain than with other regions. METHODS We did a computer-aided search of MEDLINE, BIDS ISI, and PsychLit databases supplemented by hand searches of key journals. We included all reports on the association of depression after stroke with the location of the brain lesion. Studies were systematically and independently examined by two investigators. Fixed-effects and random-effects meta-analyses were done. FINDINGS 143 reports were identified by the search strategy. 48 were eligible for inclusion. Not all reports included original data. Only two reports of original data supported the hypotheses and seven clearly did not. The pooled (random-effects) relative risk of depression after a left-hemisphere stroke, compared with a right-hemisphere stroke, was 0.95 (95% CI 0.83-1.10). For depression after a left anterior lesion compared with all other brain areas the pooled (random-effects) relative risk was 1-17 (0.87-1.62). Restriction of the analyses to reports from high-quality studies or major depressive disorder did not substantially affect the findings. Nor were they affected by stratification of the time between stroke and the assessment of depression. Multiple publications from the same samples of patients were apparent. INTERPRETATION This systematic review offered no support for the hypothesis that the risk of depression after stroke is affected by the location of the brain lesion.

Anxiety Disorders in Cancer Patients: Their Nature, Associations, and Relation to Quality of Life

PURPOSE We aimed to estimate the prevalence and types of anxiety disorders diagnosed according to standardized criteria in cancer patients, to compare screening tools in detecting them, and to examine their demographic, oncologic, and psychosocial associations. METHODS In this cross-sectional observational study of 178 subjects with lymphoma, renal cell carcinoma, malignant melanoma, or plasma cell dyscrasia, we related responses to questionnaires (administered by computer touch-screen) measuring psychological symptoms, quality of life (QOL), and social support to standardized psychiatric interviews and cancer management. RESULTS Forty-eight percent of subjects reported sufficient anxiety for anxiety disorder to be considered. At subsequent diagnostic interview, 18% fulfilled International Classification of Disorders, 10th Revision criteria for anxiety disorder, including 6% of patients who reported low levels of anxiety by questionnaire. When subjects reported anxiety by questionnaire, if disruptive somatic anxiety was present, this increased the probability of diagnosable anxiety disorder from.31 to.7. The most accurate screening questionnaires were the trait scale of the State-Trait Anxiety Inventory and the Hospital Anxiety and Depression scale. Female sex and negative aspects of social support were associated with anxiety disorder in multivariate analyses. Anxiety disorder was independently associated with a deficit in QOL, particularly insomnia. CONCLUSION Anxiety symptoms are common in cancer patients. Screening by questionnaire seems to assess anxiety symptoms adequately but discriminates abnormal anxiety inadequately. To improve this, we may need to use criteria such as disruption from anxiety, as illustrated by the impact of anxiety disorders on QOL. There seem to be few oncologic variables that could target screening for anxiety disorders.

Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition

Abstract Objective: To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves. Design: Systematic review of randomised controlled trials of psychosocial and physical treatments. Studies categorised according to type of treatment. When there was more than one investigation in a particular category a summary odds ratio was estimated with the Mantel-Haenszel method. Setting: Randomised trials available in electronic databases in 1996, in the Cochrane Controlled Trials Register in 1997, and from hand searching of journals to 1997. Subjects: Patients who had deliberately harmed themselves shortly before entry into the trials with information on repetition of behaviour. The included trials comprised 2452 randomised participants with outcome data. Main outcome measure: Repetition of self harm. Results: 20 trials reported repetition of self harm as an outcome variable, classified into 10 categories. Summary odds ratio (all for comparison with standard aftercare) indicated reduced repetition for problem solving therapy (0.73; 95% confidence interval 0.45 to 1.18) and for provision of an emergency contact card in addition to standard care (0.45; 0.19 to 1.07). The summary odds ratios were 0.83 (0.61 to 1.14) for trials of intensive aftercare plus outreach and 1.19 (0.53 to 2.67) for antidepressant treatment compared with placebo. Significantly reduced rates of further self harm were observed for depot flupenthixol versus placebo in multiple repeaters (0.09; 0.02 to 0.50) and for dialectical behaviour therapy versus standard aftercare (0.24; 0.06 to 0.93). Conclusion: There remains considerable uncertainty about which forms of psychosocial and physical treatments of patients who harm themselves are most effective. Further larger trials of treatments are needed. Key messages A systematic review of the effectiveness of psychosocial and drug treatments of patients who deliberately harm themselves identified 20 randomised controlled trials in which repetition of self harm was reported as an outcome Promising results were found for problem solving therapy, provision of a card to allow patients to make emergency contact with services, depot flupenthixol for recurrent self harm, and long term psychological therapy for female patients with borderline personality disorder and recurrent self harm Assertive outreach can help to keep patients in treatment Nearly all the trials included too few patients to detect clinically significant differences in repetition of self harm, and even synthesis of results by meta-analysis did not have the power to detect such differences There is an urgent need for large trials of promising therapies for this substantial clinical population

Selective serotonin reuptake inhibitors: meta-analysis of efficacy and acceptability.

OBJECTIVE--To examine the evidence for using selective serotonin reuptake inhibitors instead of tricyclic antidepressants in the first line treatment of depression. DESIGN--Meta-analysis of 63 randomised controlled trials comparing the efficacy and acceptability of selective serotonin reuptake inhibitors with those of tricyclic and related antidepressants. MAIN OUTCOME MEASURES--Improvement in mean scores on Hamilton depression rating scale for 53 randomised controlled trials. Pooled drop out rates from the 58 trials which reported drop out by treatment group. RESULTS--Among the 20 studies reporting standard deviation for the Hamilton score no difference was found in efficacy between serotonin reuptake inhibitors and tricyclic and related antidepressants (standardised mean difference 0.004, 95% confidence interval -0.096 to 0.105). The difference remained insignificant when the remaining 33 studies that used the 17 item and 21 item Hamilton score were included by ascribing weighted standard deviations. The odds ratio for drop out rate in patients receiving serotonin reuptake inhibitors compared with those receiving tricyclic antidepressants was 0.95 (0.86 to 1.07). Similar proportions in both groups cited lack of efficacy as the reason for dropping out but slightly more patients in the tricyclic group cited side effects (18.8% v 15.4% in serotonin reuptake group). CONCLUSIONS--Routine use of selective serotonin reuptake inhibitors as the first line treatment of depressive illness may greatly increase cost with only questionable benefit.

Mortality at 12 and 24 Months After Stroke May Be Associated With Depressive Symptoms at 1 Month

Background and Purpose— Previous studies have reported mood symptoms after stroke to be a risk factor for later mortality. The purpose of the study was to examine whether mood symptoms at 1 month after stroke may be a risk factor for mortality at 12 and 24 months. Methods— As a cohort within a randomized controlled trial, 448 hospital patients were seen at 1 month after stroke and were randomized into a trial of psychological therapy. Follow-up was at 12 and 24 months. Mood symptoms were assessed by the Present State Examination and the General Health Questionnaire (GHQ)-28. Measures of disability before and after stroke and of cognitive impairment after stroke were also taken at 1 month. Mortality was determined at 12 and 24 months after stroke. Results— In logistic regression analyses, mortality at 12 months was associated unifactorally with scoring on the GHQ-D subscale (odds ratio [OR] 2.4, 95% CI 1.3 to 4.5) and scoring in the highest quartile of the GHQ (OR 3.1, 95% CI 1.1 to 8.8). In multiple logistic regression analyses, only GHQ-D remained a significant predictor after controlling for other known predictors. At 24 months, scoring on GHQ-D (OR 2.4, 95% CI 1.4 to 4.1) and in the highest GHQ quartile (OR 2.2, 95% CI 1.0 to 4.8) was significantly associated with mortality in unifactoral analyses. Scoring on the GHQ-D remained a predictor of mortality after controlling for other variables. Psychiatric disorder, such as major depression (according to International Classification of Diseases, 10th Revision), was not statistically significantly associated with increased mortality at 12 or 24 months. Conclusions— Mood symptoms on a self-reported rating scale were associated with 12- and 24-month mortality after stroke, after adjustment for factors associated with stroke severity. The result is in keeping with other evidence that depressive symptoms are a risk factor for death from vascular disease.

Screening and case-finding instruments for depression: a meta-analysis

Background: Screening and case-finding has been proposed as a simple, quick and cheap method to improve the quality of care for depression. We sought to establish the effectiveness of screening in improving the recognition of depression, the management of depression and the outcomes of patients with depression. Methods: We performed a Cochrane systematic review of randomized controlled trials conducted in nonmental health settings that included case-finding or screening instruments for depression. We conducted a meta-analysis and explored heterogeneity using meta-regression techniques. Results: Sixteen studies with 7576 patients met our inclusion criteria. We found that the use of screening or case-finding instruments were associated with a modest increase in the recognition of depression by clinicians (relative risk [RR] 1.27, 95% confidence interval [CI] 1.02 to 1.59). Questionnaires, when administered to all patients and the results given to clinicians irrespective of baseline score, had no impact on recognition (RR 1.03, 95% CI 0.85 to 1.24). Screening or case finding increased the use of any intervention by a relative risk of 1.30 (95% CI 0.97 to 1.76). There was no evidence of influence on the prescription of antidepressant medications (RR 1.20, 95% CI 0.87 to 1.66). Seven studies provided data on outcomes of depression, and no evidence of an effect was found (standardized mean difference –0.02, 95% CI –0.25 to 0.20). Interpretation: If used alone, case-finding or screening questionnaires for depression appear to have little or no impact on the detection and management of depression by clinicians. Recommendations to adopt screening strategies using standardized questionnaires without organizational enhancements are not justified.

Routinely administered questionnaires for depression and anxiety: systematic review

Abstract Objectives: To examine the effect of routinely administered psychiatric questionnaires on the recognition, management, and outcome of psychiatric disorders in non-psychiatric settings. Data sources: Embase, Medline, PsycLIT, Cinahl, Cochrane Controlled Trials Register, and hand searches of key journals. Methods: A systematic review of randomised controlled trials of the administration and routine feedback of psychiatric screening and outcome questionnaires to clinicians in non-psychiatric settings. Narrative overview of key design features and end points, together with a random effects quantitative synthesis of comparable studies. Main outcome measures: Recognition of psychiatric disorders after feedback of questionnaire results; interventions for psychiatric disorders; and outcome of psychiatric disorders. Results: Nine randomised studies were identified that examined the use of common psychiatric instruments in primary care and general hospital settings. Studies compared the effect of the administration of these instruments followed by the feedback of the results to clinicians, with administration with no feedback. Meta-analytic pooling was possible for four of these studies (2457 participants), which measured the effect of feedback on the recognition of depressive disorders. Routine administration and feedback of scores for all patients (irrespective of score) did not increase the overall rate of recognition of mental disorders such as anxiety and depression (relative risk of detection of depression by clinician after feedback 0.95, 95% confidence interval 0.83 to 1.09). Two studies showed that routine administration followed by selective feedback for only high scorers increased the rate of recognition of depression (relative risk of detection of depression after feedback 2.64, 1.62 to 4.31). This increased recognition, however, did not translate into an increased rate of intervention. Overall, studies of routine administration of psychiatric measures did not show an effect on patient outcome. Conclusions: The routine measurement of outcome is a costly exercise. Little evidence shows that it is of benefit in improving psychosocial outcomes of those with psychiatric disorder managed in non-psychiatric settings.

Involving users in the delivery and evaluation of mental health services: systematic review

Abstract Objectives: To identify evidence from comparative studies on the effects of involving users in the delivery and evaluation of mental health services. Data sources: English language articles published between January 1966 and October 2001 found by searching electronic databases. Study selection: Systematic review of randomised controlled trials and other comparative studies of involving users in the delivery or evaluation of mental health services. Data extraction:Patterns of delivery of services by employees who use or who used to use the service and professional employees and the effects on trainees, research, or clients of mental health services. Results: Five randomised controlled trials and seven other comparative studies were identified. Half of the studies considered involving users in managing cases. Involving users as employees of mental health services led to clients having greater satisfaction with personal circumstances and less hospitalisation. Providers of services who had been trained by users had more positive attitudes toward users. Clients reported being less satisfied with services when interviewed by users. Conclusions: Users can be involved as employees, trainers, or researchers without detrimental effect. Involving users with severe mental disorders in the delivery and evaluation of services is feasible.

Anxiety in cancer patients.

Anxiety is common in cancer patient populations, and must often initially be recognized and managed by cancer care professionals. This article reviews the recent oncology and mental health literature on anxiety. The aim is to help those involved in cancer patient care who are not specialists in mental health to understand the nature of anxiety, and discriminate morbid from normal anxiety. We review recent research into the association of anxiety with events during diagnosis and management of cancer, highlighting the importance of the meaning of events to an individual as an important factor in making people anxious. Lastly we review management strategies which might be used by cancer care professionals, in particular the importance of an awareness of specific patterns of communication which may alleviate or maintain anxiety for some cancer patients.

Developing a framework for transferring knowledge into action: a thematic analysis of the literature

Objectives Although there is widespread agreement about the importance of transferring knowledge into action, we still lack high quality information about what works, in which settings and with whom. While there are a large number of models and theories for knowledge transfer interventions, the majority are untested, meaning that their applicability and relevance is largely unknown. This paper describes the development of a conceptual framework of translating knowledge into action and discusses how it can be used for developing a useful model of the knowledge transfer process. Methods A narrative review of the knowledge transfer literature identified 28 different models which explained all or part of the knowledge transfer process. The models were subjected to a thematic analysis to identify individual components and the types of processes used when transferring knowledge into action. The results were used to build a conceptual framework of the process. Results Five common components of the knowledge transfer process were identified: problem identification and communication; knowledge/research development and selection; analysis of context; knowledge transfer activities or interventions; and knowledge/research utilization. We also identified three types of knowledge transfer processes: a linear process; a cyclical process; and a dynamic multidirectional process. From these results a conceptual framework of knowledge transfer was developed. The framework illustrates the five common components of the knowledge transfer process and shows that they are connected via a complex, multidirectional set of interactions. As such the framework allows for the individual components to occur simultaneously or in any given order and to occur more than once during the knowledge transfer process. Conclusion Our framework provides a foundation for gathering evidence from case studies of knowledge transfer interventions. We propose that future empirical work is designed to test and refine the relevance, importance and applicability of each of the components in order to build a more useful model of knowledge transfer which can serve as a practical checklist for planning or evaluating knowledge transfer activities.